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Child Health Programme in India

INTRODUCTION

The child health programme under the National Health Mission (NHM) comprehensively integrates interventions that improve child survival and addresses factors contributing to infant and under-five mortality. It is now well recognised that child survival cannot be addressed in isolation as it is intricately linked to the health of the mother, which is further determined by her health and development as an adolescent. Therefore, the concept of Continuum of Care, that emphasises on care during critical life stages in order to improve child survival, is being followed under the national programme. Another dimension of this approach is to ensure that critical services are made available at home, through community outreach and through health facilities at various levels (primary, first referral units, tertiary health care facilities). The newborn and child health are now the two key pillars of the Reproductive, Maternal, Newborn, Child and Adolescent health (RMNCH+A) strategic approach, 2013.

NEWBORN AND CHILD HEALTH INTERVENTIONS:

1. FACILITY BASED NEWBORN CARE

Facility Based Newborn Care (FBNC) is one of the key components under the National Health Mission to improve the status of newborn health in the country. A continuum of newborn care has been established with the launch of home based and facility based newborn care components ensuring that every newborn receives essential care right from the time of birth and first 48 hours at the health facility and then at home during the first 42 days of life. Newborns identified as sick or preterm /low birth weight soon after birth or during home visit are referred to special newborn care facilities for further management and long term follow up after discharge.

Newborn Care Corners (NBCCs) are established at delivery points to provide essential newborn care at birth, while Special Newborn Care Units (SNCUs) and Newborn Stabilization Units (NBSUs) provide care for sick newborns. As on February 2015, a total of 14,163 NBCCs, 1,904 NBSUs and 565 SNCUs have been made operational across the country.

SNCU Online Reporting Network is being established in 7 states with 245 SNCUs to generate real time data. About 2.5 lakhs newborns have been registered in the data base.

Janani Shishu Suraksha Karyakram (JSSK): Complete elimination of out of pocket expenses with provision of free transport, drugs, diagnostics and diet to all sick new borns and infants is being ensured in the country. About 12 lakhs sick infants availed services under JSSK till December, 2014 in 2014-15.

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1.3 lakhs health care providers have been trained in essential newborn care and resuscitation under Navjaat Shishu Suraksha Karyakram (NSSK) programme that are placed at delivery points. Ensuring Injection vitamin K in all the births in the facility: All the public and private health facilities should ensure single dose of Injection Vitamin K prophylaxis at birth even at the sub centre by ANM. The States/UTs has to ensure the supplies of Injection Vitamin K1, 1mg /ml along with the disposable syringe1ml with needle no 26. The state has to make necessary procurement. A detailed operational guideline has developed and disseminated in September, 2014. Up scaling of Kangaroo Mother Care (KMC) in health facility: Up to half a million newborns could be saved each year if kangaroo care was promoted everywhere. Each state to have a model unit for training site and all the rest of the units can start with renovation and some additions. A detailed operational guideline has developed and disseminated in September, 2014. Empowering frontline health service providers: The ANMs are now empowered to give a pre referral dose of antenatal corticosteroid (Injection Dexamethasone) in pregnant women going into preterm labour and pre-referral dose of Injection Gentamicin and Syrup Amoxicillin to newborns for the management of sepsis in young infants (upto2 months of age). Availability of logistics, Capacity building and job-aides will be ensured for implementing the activities.

GOI has recommended a single course of Injection Dexamethasone (4 doses) to all the pregnant women who go in true preterm labour between 24-34 weeks. The ANMs are also empowered to ensure Antenatal Prereferral dose of Injection Corticosteroids while referring a pregnant mother in true preterm labour between 24-34 weeks. She will complete the course in case referral is not possible or refused. A detailed operational guideline has developed and disseminated in September, 2014. National Training Package for Facility Based Newborn Care: has been developed with participation of national neonatal experts in the Country. This package will improve the cognitive knowledge and build psychomotor skills of the medical officers and staff nurses posted in these units to provide quality newborn care. The training includes 4 day class room training and 14 day observership training in smaller batches. Establishing Network of Resource (Collaborative) Centres: Currently there is only one National Collaborating Centre and 4 regional Collaborating centre to provide observer ship training for FBNC. The plan is to have 6 state perinatal resource centres in the initial phase and then upscale it to at least each state having its own Collaborative Centre for training, mentoring, supportive supervision and data collection.

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India Newborn Action Plan (INAP): On 18th Sept 2014, India Newborn Action Plan was launched in response to Global Newborn Action Plan. INAP lays out a vision and a plan for India to end preventable newborn deaths, accelerate progress, and scale up high-impact yet cost-effective interventions. INAP has a clear vision supported by goals, strategic intervention packages, priority actions, and a monitoring framework. For the first time, INAP also articulates the Government of India’s specific attention on preventing still births. With clearly marked timelines for implementation, monitoring and evaluation, and scaling-up of proposed interventions, it is expected that all stakeholders working towards improving newborn health in India will stridently work towards attainment of the goals of “Single Digit Neonatal Mortality Rate by 2030” and “Single Digit Still Birth Rate by 2030”.

2. HOME BASED NEWBORN CARE SCHEME Keeping the spirit of continuum of care facility based care is linked to home based newborn care which provides opportunity for early diagnosis of danger signs, prompt referral to an appropriate health facility with provision for newborn care facility, saves lives. All the rural live births are targeted to receive home based new born care through series of home visit by ASHAs and as a result ASHA is being paid of Rs. 250/- on completion of the visit. The sick and low birth weight babies will need extra visits. More than 20 lakhs newborns are visited by ASHAs as on December, 2014. In addition, ASHAs are now entitled to receive incentive of Rs. 50/- for Ensuring monthly follow up of low birth weight babies and newborns discharged after treatment from Specialized New Born Care Units.

3. CHILD DEATH REVIEW

Child health division, Ministry of Health & Family Welfare have been developed the operational guideline of Child Death Review (CDR) and disseminated on 18th September, 2014. CDR is being implemented across the country for the corrective action for implementation of Child Health Interventions as per detailed review of causes of death and reason for delay if any for Neonate, Infant and Child deaths.

4. INFANT AND YOUNG CHILD FEEDING

Promotion of optimal IYCF practices and management of lactational failure/breast related conditions such as Home Based New Born Care visitations, VHND, Outreach sessions for Routine Immunisation, RI sessions at facilities, management of newborn and childhood illnesses at community level. Provision has been made for trainings of Medical Officer, frontline workers on the subject at every level of Health facility, nutritional counsellor at high case load facilities, Information, Education and Communication and Behaviour Change Communication as well monitoring of the programme.

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5. NUTRITIONAL REHABILITATION CENTRES (NRC)

Nutritional Rehabilitation Centers are facility based units providing medical and nutritional therapy to children with Severe Acute Malnourished under 5 years of age with medical complications. In addition special focus is on improving the skills of mothers on child care and feeding practices so that child continues to receive adequate care at home. Expansion of NRCs has been ensured in High Need Areas such tribal blocks. A total of 891 NRCs have been established in the country as on February, 2015.

The training package for facility based care of Severe Acute Malnutrition in Children has been developed to train staff of Nutritional Rehabilitation Centres on diagnostic and treatment protocols. The package aims to improve the clinical skills of the Medical Officers and Nursing staff of NRCs, particularly for the management of children with SAM.

In addition, ASHAs are now entitled to receive incentive of Rs. 150/- for follow up visits after child is discharged from facility or community based SAM management and till MUAC is equal to or more than 125mm.

6. SUPPLEMENTATION WITH MICRONUTRIENTS Iron Folic Acid Supplementation and deworming to children (6 months to 59 months)

and children (6-10 years): Bi-weekly IFA syrup to children 6m – 5 years and weekly IFA tablets to children (6-10 years) and bi-annual deworming to children 1-10 years is part of the National Iron Plus Initiative, which lays a renewed emphasis on tackling high prevalence of anaemia comprehensively across age groups. The national guidelines have been released by Ministry of Health & Family Welfare, in January, 2013. The details of the guidelines have been circulated to all states and UTs for compliance. States/UTs have budgeted for the components in the NHM PIP 2014-15. 99.47 lakhs IFA syrup given to the Children as on December, 2014.

Vitamin A Supplementation in under-five children: Under the national programme, 1st dose of Vitamin A (1 lakh I.U.) is being given to the child at the time of immunization at 9 months of age, and thereafter, the child is administered doses of Vitamin A (2 lakh I.U. of Vitamin A) at 6 monthly interval, so that a child receives a total of 9 doses of Vitamin A till the age of 59 months. Bi-annual rounds for Vitamin A supplementation would be conducted in all States & UTs with the co-ordination between Health & ICDS functionaries. As on December, 2014 HMIS 2014-15; 54.6%, 46.4% and 42.0% children received the 1st, 5th and 9th dose of Vitamin A respectively.

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7. REDUCTION IN MORBIDITY AND MORTALITY DUE TO ACUTE RESPIRATORY INFECTIONS (ARI) AND DIARRHOEAL DISEASES

Childhood Diarrhoeal Diseases

States/UTs were supervised for procurement of ORS and Zinc and its supplies at each public health facility and ASHA who is the village level depot holder of ORS packets and Zinc tablets. It is to be ensured that Zinc and ORS is provided to all cases of childhood diarrhoea seeking care at DH/CHC/PHC/Additional PHC/Sub Centres.

The aim is that every child treated for diarrhoea should get one/two ORS packets along with 14 tablets of Zinc and counselling for feeding at the start of therapy, and counselled properly for continued administration.

In order to control deaths due to diarrhea and generate awareness in the community, an Intensified Diarrhoea Control Fortnight (IDCF) was implemented this year from 28th July to 8th August 2014 all over the country with the ultimate aim of ‘zero child deaths due to childhood diarrhoea’. For heightened impact of the fortnight, pertinent role of other sectors namely-Education Department, apart from Panchayti Raj Institutions and Women and Child Development was also envisaged. Dedicated funding is provided for these activities @ Rs. 10 lakh per district. During Fortnight health workers will visit the households of under five children, conduct community level awareness generation activities, distribute ORS packets to the families with children under five years of age, ORS corners will be set up in health facilities, and Anganwadi Centres. Health workers conducted counselling sessions on appropriate methods of Infant and Young Child feeding practices, hygiene and sanitation. As this campaign has already been implemented, around 2 Crore families were reached at doorstep for delivery of ORS packet by ASHA worker for their under-five children. 1.1 lakhs Schools participated, and 1.9 lakh ORS- zinc corners were established in health facilities. 36.08 lakh children were monitored for weight gain and sickness.

Acute respiratory infections

While acute upper respiratory tract infections are very frequent in children, pneumonia is the leading cause of under-five mortality. Early recognition and treatment of pneumonia can be lifesaving. For children with non-severe pneumonia the ARI control program recommends oral Cotrimoxazole as the first line drug. This is supplied at the subcentre level and is recommended as drug for community based management of pneumonia by frontline health workers.

Amoxicillin has been recommended as the preferred drug for treatment of non-severe pneumonia at facility level by the physician. It has been estimated that about 10% of

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children presenting with pneumonia may require referral for hospital based management. Use of oxygen and injectable antibiotics is recommended for inpatient treatment of severe cases and the recommended antibiotics included in the essential drug list.

Provisions have been made for procuring required equipments such as Nebulisers, Pulse Oxymeters and relevant antibiotics at each level.

A detailed Pneumonia and ARI guidelines is also being developed to assist States with Standard treatment protocols and operational strategies to improve preventive and treatment services.

Integrated Management of Neonatal and childhood illnesses (IMNCI): Medical officers and staff nurses would be trained in facility based IMNCI to provide care to sick children and newborns at CHCs/FRUs. Harmonisation of various training packages is being undertaken for effective coverage of training.

8. RASHRTIYA BAL SWASTHYA KARYAKRAM (RBSK)

This initiative was launched in February 2013 for Early Child Health Screening and Early Intervention Services through early detection and management of 4 Ds i.e Defects at birth, Diseases, Deficiencies, Development delays including disability are to cover 30 selected health conditions for early detection, management and free treatment. An estimated 27 crore children in the age group of zero to eighteen years are expected to be covered across the country in a phased manner.

As on December 2014, a total of 5418 RBSK teams have been recruited. About 12.19 crore children have been screened and 60.8 lakhs children have been referred to health facilities for the treatment. About 16.8 lakhs children have received secondary and tertiary care. A total of 445 State level master trainers and 2429 Teams from 9 states were directly trained by the National RBSK Team.